JMIR Publications

ABSTRACT

Background:

People with multimorbidity have complex healthcare needs resulting in high health service utilization, hospital readmission rates and extensive intervention and support. To prevent unnecessary hospital readmissions, effective coordination during the transition from hospital to primary care is essential. The past decade has seen the Transition Care Model (TCM) emerge as an effective approach to reducing hospital readmissions and addressing care fragmentation for this vulnerable population. This study will adapt the TCM, focussing on a nurse-led telehealth-based follow-up transition coordination service to enhance continuity between hospital and primary care, aiming to reduce unnecessary hospital readmissions and improve patient transitions.

Objective:

The key objective of this research is to assess the impact of a transitional care model on three-month readmission rates in people with multimorbidity post- discharge, in an Australian context. Other objectives include: rate of representation to hospital (emergency department or hospital admission) and overall length of hospital stay within 1, 6 and 12 months of discharge from index admission; calculating a cost analysis on the transitional service model of care; evaluating the patient experience with continuity of care and the transition service; assessing patients’ symptom burden pre and post transitional support service intervention; and evaluating patients’ quality of life, self-efficacy, and symptom management, pre and post intervention.

Methods:

The study design is a multi-centre pragmatic randomised controlled trial (pRCT) of patients with multimorbidity. As this is a pRCT, real-world clinical practices, patient flow, and operations will be considerations within the research design elements. A mixed methods approach using quantitative and qualitative data collection methods will be employed. The study setting will be multi-centre, commencing at a 355-bed acute and sub-acute teaching hospital, progressing to an 880-bed acute care teaching hospital, both located within the South Australian, Central Adelaide Local Health Network (CALHN). Between three and six medical units and wards will be included. The intervention will focus on nurse-led transition assessment and care planning, and telehealth transition coordination support, for people with multimorbidity, for 6-10 weeks, following hospital discharge.

Results:

This project received ethics approval [reference number 17554] 29 June 2023, and was registered with the Australia and New Zealand Clinical Trial Registry on the 15th of February 2024 (ACTRN reference number 12624000142538). The study commenced on 1 July 2023, and will complete 31 March 2025. Finalised results are expected March 2026.

Conclusions:

The Central Adelaide Local Health Network currently lacks a process to assess or manage readmission risks for people with multimorbidity, despite evidence linking transitional care to reduced rehospitalizations. The researchers’ previous feasibility study highlighted the effectiveness of a transition coordinator role in supporting patients' return to home and community. Progressing the feasibility study, an adapted TCM, with telehealth-based follow-up service with home and healthcare support will enhance continuity between hospital and primary care, aiming to reduce unnecessary hospital readmissions and improve patient transitions. Clinical Trial: Trial registration: Australia and New Zealand Clinical Trial Registry; (ACTRN12624000142538).